Nuclear Medicine Department Survey Workbook

Nuclear MedicineSurvey Workbook

Version 1.2

© GE Medical Systems Healthcare Services

© GE Medical Systems Healthcare Services3

THE NUCLEAR MEDICINE DEPARTMENT SURVEY WORKBOOKTABLE OF CONTENTS

Page #

The Nuclear Medicine Department Survey 4

Key Nuclear Medicine Department Survey Points to Remember 6

Nuclear Medicine Department Survey Question Categories 8

Nuclear Medicine Department Topics 12

Nuclear Medicine Department - Physical Inspection 14

Nuclear Medicine Department - Focus Issues 16

Nuclear Medicine Equipment Requirements 19

Policy and Procedure Requirements 20

Policy and Procedure Review Form 21

Potential Surveyor Questions for Nuclear Medicine Department Personnel 22

Nuclear Medicine Post Test 28

Bullet Excerpts from Video 31


THE NUCLEAR MEDICINE DEPARTMENT SURVEY

The purpose of this workbook is to provide assistance to your Nuclear Medicine Department staffin preparation for your JCAHO Survey. The healthcare professionals at Medical ConsultantsNetwork Inc. encourage you to use the information provided as a “working tool”, documentingways in which your Nuclear Medicine Department can meet compliance.

The first step in preparing for the Nuclear Medicine Department survey is to consider which staffmembers you would like to represent your Nuclear Medicine Department during the actual surveyprocess. It is recommended that staff members who become easily intimidated by the inspectionprocess or those that tend not to answer questions well, should not be scheduled to work on thedays of survey. We encourage you to discuss the survey process with all of your NuclearMedicine Department staff and decide, as a group, which staff members would like to participatein the JCAHO survey process. Utilizing this information, it should then be decided which staffmembers have the following capabilities:

• Concrete knowledge of Nuclear Medicine Department rules and regulations, in accordancewith JCAHO, state and federal standards, laws and mandates

• An strong understanding of the JCAHO functions as listed in the Comprehensive AccreditationManual for Hospitals (CAMH)

• A good working knowledge of how the Nuclear Medicine Department operates, includingknowledge of the department’s policies and procedures

• Basic knowledge of your organization’s mission and values, including hospitalwide policies andprocedures

• Presents themselves with a sense of confidence and assuredness

These will be the staff members that you should strongly consider scheduling to work during yoursurvey dates.

Objectives

At the completion of this video and workbook you will understand:

• How the survey process will look and feel

• How the surveyor interacts with the department staff

• What areas within your department the surveyor will most likely inspect

• How to best prepare for a JCAHO survey


In preparing for your Nuclear Medicine Department survey, make a list below of those individualsin your organization whom you feel will be best suited to represent the Nuclear MedicineDepartment during the JCAHO survey, and list why. After a thorough list has been made, askthese individuals to study the Nuclear Medicine Department Survey Video again, to determine ifhe or she feels they will be beneficial as an active participant in the survey process.

Name Position Choice Rationale

Names of Participants Selected:


KEY NUCLEAR MEDICINE DEPARTMENT SURVEY POINTS TO REMEMBER

• If you do not understand a surveyor’s question, ask the surveyor to restate the question.Frequently a surveyor’s question is a JCAHO standard, restated in question format. Also, it isnot uncommon for a surveyor to provide “clues” to the expected answer within a restatedquestion.

• Structure your answers to highlight collaborative endeavors undertaken by your departmentand the facility as a whole. Review potential question categories prior to the survey, andidentify how you, your staff, your department and the organization provide care in acollaborative fashion.

• Your surveyor may interview staff singularly or in a group format. It is best to plan for bothtypes of interview processes. If, in the group format interview, it is noted that a coworkerseems to be having difficulty answering a surveyor’s question, do not hesitate to provideassistance with the answer. Do not contradict a participant’s answer, even if you feel theanswer is incorrect. Try and find a way to supplement their answer with the correctinformation that does not give the surveyors the impression the answer was incorrect.Examples:

! “What I think Jane is trying to say is …….. give correct answer”

! “Perception is key in understanding this process ……. give correct answer”

! “Conceptually, there is a measure of validity, however we’ve entered a new phase with anew set of processes ……. give correct answer”

• Never attempt to answer a surveyor’s question if you do not know the answer, and never tryand “bluff” your answer. If none of the interview participants answer a given question, thesurveyor will elaborate on the intent of the question, thereby providing the interviewparticipants with an increased understanding of how to approach the answer correctly.

• It is acceptable to state to the surveyor “I’m not sure I’m answering your question correctly, butI believe what you are asking is . . . . .” Often, interview participants are uncertain if theiranswers will be correct, or if their response will satisfy the surveyor. By prefacing your answerwith an honest “I’m not completely sure I’m addressing the intent of your question” and similarstatements, the interview participant reduces the risk of being perceived as incorrect by thesurveyor.

• It is also acceptable to state to the surveyor “I can find the answer to your question byreviewing my policy and procedure manual.” Remember that the surveyor doesn’t expect youto know the answer to every question, verbatim. Retrieving a policy and procedure manual andshowing the surveyor where the policy is located that answers his/her question, will meet withsurveyor satisfaction. (Note: Ensure your departmental and organizational policy andprocedure manuals are current, with all necessary administrative and medical staff approvals –prior to survey).


• The Nuclear Medicine Department staff is expected to be well versed in diagnostic nuclearmedicine procedures and radiation safety issues. Make sure all Nuclear Medicine Departmentstaff can discuss all components of the

• Nuclear Medicine environment.

• Because many Nuclear Medicine Departments deal with a variety of diagnostic equipment,make sure all staff can confidently discuss such issues as the education and training theyhave received regarding equipment use and maintenance and device failure reporting.

• Proper storage and handling of radioactive materials will be a focus point for your surveyor.Carefully inspect both your hot and cold labs, assuring that all safety precautions are in place.


NUCLEAR MEDICINE DEPARTMENT SURVEY QUESTION CATEGORIES

• Patient rights, advance directives (such as Do Not Resuscitate [DNR]), protection of patientdignity and confidentiality of patient information

• Emergency imaging processes, on-call staff availability and expected response time

• Performance improvement activities that have been conducted by the Nuclear MedicineDepartment staff (in a collaborative manner and interdepartmentally)

• Determination of licensed independent practitioner (physician) competency (for example, howare radiologists proctored to assure competency when performing new procedures?)

• Reporting of complications

• Sentinel event identification, reporting, analysis and resolution

• Departmental policy and procedure development and implementation

• Infection control issues

• Management of radioactive materials

• Responsibility for ordering of contrast materials (i.e., Pharmacy or Imaging Department)

• Staff safety related to radiation exposure

• Disaster planning and the Nuclear Medicine Department’s involvement

• Communication to the patient’s family/support group (i.e., communication system for theImaging Department’s waiting room)

• Human resource issues: staffing, recruitment, retention

• Restraints management during imaging procedure

• Safety and the environment of care

• Staff competency, including age related and cultural competencies

• Victims of abuse identification and reporting

• ORYX and/or core measures that Nuclear Medicine Department staff may be involved inmonitoring

• Patient assessment and preparation for procedure

We suggest that your Nuclear Medicine Department staff review each category, discussing howyour department manages each issue. It is recommended that your collective answers besummarized and documented in the space provided in this workbook. Your staff should reviewthese answers frequently prior to survey.


Patient rights, advance directives (such as DNR), protection of patient dignity and confidentialityof patient information:

_____________________________________________________________________________

_____________________________________________________________________________

Emergency Nuclear Medicine processes, on-call staff availability and expected response time:

_____________________________________________________________________________

_____________________________________________________________________________

Performance improvement activities conducted in the Nuclear Medicine Department:

_____________________________________________________________________________

_____________________________________________________________________________

Assurance of physician competency:

_____________________________________________________________________________

_____________________________________________________________________________

Reporting of complications:

_____________________________________________________________________________

_____________________________________________________________________________

Sentinel events, root cause analysis, corrective action plan:

_____________________________________________________________________________

_____________________________________________________________________________

Departmental policy and procedure development and implementation:

_____________________________________________________________________________

_____________________________________________________________________________


Infection control issues:

_____________________________________________________________________________

_____________________________________________________________________________

Management of radioactive materials:

_____________________________________________________________________________

_____________________________________________________________________________

Responsibility for ordering of contrast materials:

_____________________________________________________________________________

_____________________________________________________________________________

Staff safety related to radiation exposure:

_____________________________________________________________________________

_____________________________________________________________________________

Disaster planning and the Nuclear Medicine Department’s involvement:

_____________________________________________________________________________

_____________________________________________________________________________

Communication to the patient’s family/support group:

_____________________________________________________________________________

_____________________________________________________________________________

Human resource issues: staffing, recruitment and retention

_____________________________________________________________________________

_____________________________________________________________________________


Restraints management:

_____________________________________________________________________________

_____________________________________________________________________________

Safety issues and the environment of care in the Nuclear Medicine Department:

_____________________________________________________________________________

_____________________________________________________________________________

Evaluation and verification of staff competency:

_____________________________________________________________________________

_____________________________________________________________________________

Victims of abuse identification and reporting:

_____________________________________________________________________________

_____________________________________________________________________________

ORYX and/or core measures:

_____________________________________________________________________________

_____________________________________________________________________________

Patient assessment and preparation for procedure:

_____________________________________________________________________________

_____________________________________________________________________________


NUCLEAR MEDICINE DEPARTMENT TOPICS

The Nuclear Medicine department must deal with a variety of situations that are unique to theperformance of diagnostic imaging tests and procedures. Review the topics below, discussingwith your Nuclear Medicine staff how your department manages each issue. Write yourconclusions in summary format for review by all department members – to prepare yourdepartment for surveyor inquiry on these subjects:

• Radiation Physicist inspection reports:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Equipment procurement, maintenance and biomedical certification:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Use of outside services (including assurance of outside service competency and quality):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Education and training on new equipment:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


• Quality control activities (equipment calibration, etc.):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Procurement of radioactive materials in emergency situations:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Medication management and safe storage within the unit:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Storage and use of radioactive materials (including record-keeping procedures):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• Other unique circumstances:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


NUCLEAR MEDICINE DEPARTMENTPHYSICAL INSPECTION

During the JCAHO surveyor’s visit to the Nuclear Medicine Department, he/she will tour andphysically inspect the department. To properly prepare for your survey, it is recommended thatyou and your staff perform your own departmental inspection of the following areas:

• Storage of radioactive materials (storage area is secured and locked at all times)

• Assessment of the crash cart(s)

! Crash cart check - per your policy, has the check sheet been completed and initialed

! Does the check include integrity of the lock and documentation of lock number

! Does the check include charging defibrillator to specified jules, both on and off batterypack, per manufacturer’s recommendations

! Assure all medications and sterile supplies do not exceed expiration dates

! Assure that all necessary equipment is available (pediatric scope and paddles, oxygen tankis full, suction machine available, etc.)

• The medication refrigerator (if used in your department) is clean and:

! Is refrigerated at the appropriate temperature

! Contains a daily temperature assessment log

! Contains only medications (i.e., no patient or staff food)

• Medication supplies are locked, secured from patient or visitor access

• Expiration dates on all medications and supplies are not exceeded, this includes medicationskept in the medication refrigerator (note: special emphasis on appropriate dating ofmedication vials – pursuant to hospital policy and procedure)

• Narcotics control sheet is complete and accurate for usage and wastage

• Any stock drugs or drugs contained in a “transport box” are located in a locked, secure areaand are not expired

• Sharps disposal containers are filled with sharps only (no paper, empty plastic vials, etc.) andare not overfilled


• If your facility utilizes sharps disposal containers that include a locking device, assure that thelocking device is present and functional

• Hazardous materials waste containers are filled with hazardous materials only (i.e., not filledwith used paper patient gowns, non-saturated dressings)

• Hazardous materials waste containers are covered and protected from patient or visitoraccess

• Radiation exposure equipment (lead aprons, thyroid guards, etc.) is intact, without cracks, ripsor tears

• All discarded films with patient identifiers are kept in a confidential area, without access topublic view

• All patient information shown on computer screens is kept out of public view (it is advisable tohave a 30 second “walk away” feature on all computer programs where patient information isaccessible. This feature returns the user to a blank screen, when accessing patientinformation, after 30 seconds of unattended use.)

• All gurneys have working brakes and side rails – integrity of gurney pad is intact (no rips ortears)

• Evidence of Radiation Physicist review and approval via signature is readily available on policyand procedure manuals and all radiation safety and performance improvement (includingquality control activities) documentation

• All nuclear medicine exam rooms have operational “in use” sign, clearly visible to public andstaff

• State license for all types of nuclear medicine procedures performed is posted and clearlyvisible to the public


NUCLEAR MEDICINE DEPARTMENTFOCUS ISSUES

Discuss with your staff how your Nuclear Medicine Department would handle the followingsituations. Document your collective conclusions below:

• Management of patients with severe adverse reactions to contrast media:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• What is the procedure for a radioactive materials spill?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• What type of special education and training does the Nuclear Medicine staff receiveregarding radiation safety issues? How does the department manager know the staff isqualified to work with radioactive materials?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


• Because conscious sedation is sometimes used in the Nuclear Medicine Department, canyou demonstrate to the surveyor that the staff is competent to administer and monitorconscious sedation? (i.e., all staff must meet the same competency requirements when thesame service is provided, regardless of location throughout the facility)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• How does the Nuclear Medicine staff manage patients with infectious diseases? Are thereany special requirements when performing a procedure on a patient that is in isolation?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• How does the department monitor and adjust staffing levels based on unexpectedemergency or “add-on” cases?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


• How do staff assure that the patient is not receiving excessive exposure to radiation (i.e., isthere a policy for requiring documentation of last menstrual period on women of child-bearing age to assure there is no chance of exposure during pregnancy?)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

• What types of educational opportunities are provided for Nuclear Medicine Departmentstaff (both physician and other healthcare provider staff)?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


NUCLEAR MEDICINE EQUIPMENT REQUIREMENTS

To demonstrate optimal patient and staff safety when Nuclear Medicine equipment is utilized, theJCAHO requires that a qualified physician, qualified medical radiation physicist or other qualifiedindividual monitors the performance evaluations of nuclear medicine therapy equipment at leastquarterly.

Additionally, your surveyor will want to assure that the hospital’s medical equipment safetyprogram includes evaluation of equipment performance by a qualified medical physicist, including:

• Radiation therapy units, radioactive sources and simulators for proper working order. Allisodose plans and calculations for each patient are verified by a qualified medical physicistprior to, or shortly after initiation of treatment, and therefore on a weekly basis. There exists aprocedure for determining whether dose delivery is consistent with the actual dose prescriptionand that total doses do not differ from the prescribed does by more that 5%.

• Periodic checks of film processors.

• A procedure for measuring the uniformity (“flood” tests) and resolution (“bar tests”) of nuclearmedicine imaging instruments.

• A maintenance program.

• Annual accuracy, daily calibration and constancy, and quarterly linearity checks are done onthe dose calibrator in Nuclear Medicine.

• Routine surveys for radiation levels and removable contamination in patient care areas inwhich radioactive materials are used.

• Review and documentation of all testing results.

• Pursuant to the JCAHO Environment of Care Standards for control of hazardous materials andwaste, policies addressing receipt, storage, transport, preparation, handling, use and disposalof radionuclides and radiopharmaceuticals.

• Documentation exists which demonstrates that there is an active Radiation Safety Committee,comprised of appropriate technical and administrative personnel.


POLICY AND PROCEDURE REQUIREMENTS

Pursuant to the JCAHO, policies and procedures are to reflect a department’s goals and scope ofservices, as well as the staff’s knowledge and skill. Policies and procedures are to describe howthe department assesses and meets the care needs of the patients and patient populations.Departments must show that the following elements have been considered in the development ofpolicies and procedures:

• Types and ages of patients served

• Methods used to assess and meet patient’s care needs

• Scope and complexity of patient’s care needs

• The appropriateness, clinical necessity and timeliness of support services provided directly bythe hospital or through referral contracts

• The availability of necessary staff

• The extent to which the level of care or service provided meets patient’s needs

• Recognized standards or practice guidelines, when available

In most instances during the provision of patient care, more than one discipline interacts with thepatient. Therefore, it is expected that policies and procedures are collaborative in nature. It isrecommended that your staff become prepared to explain this during the surveyor’s visit to theNuclear Medicine Department, as well as verify this in written format.

Your organization can achieve compliance with this important requirement in several differentways:

• Development of a policy and procedure review committee (whose membership isinterdisciplinary)

• Documentation that the policy/procedure (either formal or informal) has been reviewed by theappropriate disciplines

• Evidence in various committee meeting minutes that the policy/procedure has been reviewedin a collaborative format

Note: It is highly recommended that there be a general policy and procedure on how yourorganization and/or departments develop and implement policies and procedures.


POLICY AND PROCEDURE REVIEW FORM

List types and ages of patients served:_____________________________________________________________________________

_____________________________________________________________________________

List methods used to assess and meet patient’s care needs:_____________________________________________________________________________

_____________________________________________________________________________

What is the scope and complexity of the patient care needs?_____________________________________________________________________________

_____________________________________________________________________________

List the appropriateness, clinical necessity and timeliness of support services provided directly bythe hospital or through referral contracts:_____________________________________________________________________________

_____________________________________________________________________________

What is the availability of necessary staff, (does the department ever require nursing staff)?_____________________________________________________________________________

_____________________________________________________________________________

Describe the extent to which the level of care or service provided meets patient’s needs:_____________________________________________________________________________

_____________________________________________________________________________

List recognized standards or practice guidelines that pertain to the policy/procedure:_____________________________________________________________________________

_____________________________________________________________________________

List all departments involved with the policy/procedure:________________________ _________________________ ________________________

________________________ _________________________ ________________________

________________________ _________________________ ________________________


POTENTIAL SURVEYOR QUESTIONS FORNUCLEAR MEDICINE DEPARTMENT PERSONNEL

Review the list of possible surveyor questions, providing your answers in the space provided:

1. How is latex sensitivity addressed in the Nuclear Medicine environment?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. How do you recover patients if they have received conscious sedation?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

3. How do you involve the patient in participating in care decisions?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4. How are pharmacy services provided to the Nuclear Medicine Department when thePharmacy is closed?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

5. How do you manage pediatric medication/contrast dosing in the Nuclear MedicineDepartment if you only occasionally treat pediatric patients?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


6. How does the Nuclear Medicine staff ensure that all services are available in a timelymanner to meet the needs of the patient population?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

7. How does the Nuclear Medicine Department Manager determine if staff is competent toperform assigned duties, and when appropriate provide care for the special needs andbehaviors of specific age groups?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

8. How does the organization provide for security of patients and personnel in the NuclearMedicine Department?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

9. Describe processes conducted in your hot laboratory:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10. Describe processes conducted in your cold laboratory:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


11. Describe what elements must be included on a request (order) for a nuclear medicineprocedure:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

12. Describe safety processes conducted to assure safe receipt and transport of radioactivematerials:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

13. How is the Nuclear Medicine staff informed about the patient’s advance directive?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

14. Describe the process for performing a test on a patient with a behavior managementproblem?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

15. How does the Nuclear Medicine Department collaborate with other departments to improvepatient care and/or organizational services?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


16. What types of performance improvement activities are conducted in the Nuclear MedicineDepartment?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

17. What does your staff do if there is no informed consent for procedure on the patient’srecord prior to procedure?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

18. Describe how the patient is educated about, and prepared for, Nuclear Medicineprocedures:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

19. Describe what steps are taken in the care of the immunosuppressed patient undergoingNuclear Medicine procedures:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

20. Describe all quality control procedures conducted in the Nuclear Medicine Department:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


21. Describe what processes are in place in the Nuclear Medicine Department to assure thereis no excessive radiation exposure to patients or staff:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

22. Describe how peer review is conducted by Nuclear Medicine physician staff:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

23. List the members of the Radiation Safety Committee:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

24. What types of activities are conducted during the Radiation Safety Committee?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

25. Who is your Radiation Physicist? How often does the Radiation Physicist review yourequipment evaluation quality control activities?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


26. Describe the requirements for your Nuclear Medicine Department mandated by the NuclearRegulatory Commission. Is your state one of the “In Agreement States” regulated by Title10 of the Codified Federal Register?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Notes:

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NUCLEAR MEDICINEPOST TEST

(Circle the most correct answer)

1. Staff that are assigned to work during the JCAHO survey:

A. Should have a concrete knowledge of Nuclear Department rules and regulations

B. Should have “no nonsense” personalities

C. Should be well groomed and attractive

D. It doesn’t make any difference who is assigned to work

2. Guidelines to remember during survey include the following EXCEPT:

A. Follow the department dress code, wear your name tag

B. Maintain patient privacy and dignity

C. Take a short lunch in case the surveyor has questions

D. Follow all radiation safety regulations for Hot and Cold laboratories

3. Fire safety guidelines to remember during the JCAHO survey include:

A. The acronym for what to do in a fire, the code for fire, who is charge of the SafetyCommittee

B. The date of the last fire drill, what RACE stands for, who was working during the lastdrill

C. The code for fire, the locations of fire extinguishers, where fire pull stations are

D. Locations of fire extinguishers, the date of the last fire drill, the date of the next firedrill


4. During the review of the department, medication supplies will be inspected for:

A. Expiration dates, secure access, number of drugs in “transport” boxes

B. Complete narcotic control sheet, number of expired drugs, if a medicationrefrigerator is used

C. Availability of “transport” boxes, expiration dates, temperature of medications

D. Medications do not exceed expiration dates, complete and accurate narcotic controlsheet, medication refrigerator contains only drugs

5. During the physical inspection of the department, the surveyor will NOT:

A. Tour the Hot and Cold labs

B. Inspect lead aprons and gloves for tears

C. Ask about preparing and disposing of radioactive materials

D. Question patients without their consent

6. Which of the following is NOT a competency issue required for all areas that provideclinical care:

A. Age-specific care, as appropriate to the populations served

B. Restraint application and monitoring

C. Knowledge of theory related to procedures/treatments

D. Knowledge of Human Resources polices and procedures

7. It is not necessary to follow Standard Precautions with patients in Nuclear Medicinebecause the radiation would kill any dangerous organisms.

A. True

B. False


8. Medical records in the Nuclear Medicine Department:

A. Must be in an area that is secure and confidential, yet allows staff accessibility

B. May be stored on the floor but have proper space between ceiling and top ofstorage cabinets

C. Should be color coded to indicate the patient’s primary doctor

D. May only contain notes from the current admission

9. If conscious sedation is used in the department, all of the following is true EXCEPT:

A. It must be given by an anesthesiologist so that the same level of care is providedthroughout the facility

B. Patients must give their informed consent

C. Must be physician directed, may be RN administered

D. Physician and registered nurse must have demonstrated competency

10. The surveyor will be interested in how performance improvement activities are conductedin the department. The surveyor will want to know:

A. It is done on a bi-monthly basis

B. That the Nuclear Medicine Department conducts collaborative, interdisciplinary PIactivities

C. If the physicians have agreed to Peer Review in the department

D. How many indicators the department has monitored over the last six months

What You Will Learn From The Nuclear


Medicine Department JCAHO SurveyVideo:

• How the survey process will look and feel• Surveyor interaction with staff and participants• Areas that will likely be inspected• Types of questions asked by surveyors• How participants are expected to respond• How best to prepare for Your actual JCAHO Survey


NUCLEAR MEDICINE DEPARTMENT

ACCREDITATION SURVEYPROCESS



Survey Guidelines to Remember:

• Wear your name tag• Follow your departmental/organizational dress code• Maintain all radiation safety regulations for Hot and Cold Laboratories• Maintain patient privacy and dignity• Know organizational lines of authority• Maintain a pleasant and friendly manner• Answer surveyor questions honestly


Surveyor Arrival in Your Department


GENERAL QUESTIONS ASKEDOF STAFF



Fire Safety Guidelines to Remember:

• Know your organization’s code to be paged in the event of a fire• Know what methodology your organization follows in the event of a fire (ie. R.A.C.E.)• Be prepared to describe what R.A.C.E. means:

!Rescue!Activate alarm!Contain fire!Extinguish (if possible and safe)


Fire Safety Guidelines to Remember:

• Know location of fire extinguishers and fire alarm pull station• Know whom to call (telephone number) to have fire code paged• Know approximate date of latest departmental and organizational fire drill


PHYSICAL INSPECTION OFDEPARTMENT

Radiation Safety Guidelines to



Remember:• Be prepared to describe your department’s policy on patient and staff radiation protection• Assure that your Hot and Cold Laboratories are secured (locked) at all times• Assure that all radioactive materials are stored according to state and federal regulations

Radiation Safety Guidelines to


Remember:• Be prepared to discuss which areas must be lead lined, and explain why• Be prepared to discuss your radioactive material preparation and procedure completion processes (including wipe down, substance documentation “logging” and clean-up/disposal)• Be prepared to explain the Nuclear Medicine’s hazardous materials management program


PATIENT SAFETY



CLINICAL COMPETENCY OF STAFF

Clinical Competency Requirements


Include:• Physical performance of procedures/treatments• Knowledge of theory related to procedures/treatments• Age specific care• Cultural/religious issues• Social issues• Restraint application• Identification and reporting of abuse victims• Safety and security issues• Infection control practices


MEDICAL RECORDS ACCESS



PHYSICIAN INTERVIEW

Hazardous Materials Management


Points to Remember:• Response for toxic spill and/or exposure• Describe departmental hazardous materials protection plan• Location and storage of hazardous materials• Disposal process for hazardous and/or radioactive materials

Infection Control Guidelines to


Remember:

• Use of Standard Precautions• Use of Personnel Protective Equipment when necessary• Categories of Isolation• Departmental Infection Control issues• Management of infectious patients



PHYSICIAN DIRECTOR INTERVIEW

INTERVIEW QUESTION TOPICS


• Policy and procedure development• Patient/family education process• How continuity of care is maintained• Patient rights and advance directives• Ethical dilemmas

Conscious Sedation:


• Defined as:! Sedation, with or without analgesia, which results in the loss of protective reflexes (see workbook for complete JCAHO definition)

• Same level of care provided throughout facility, wherever conscious sedation is administered

Conscious Sedation:



• Must perform pre-anesthesia assessment• Must obtain patient’s informed consent• Must monitor patient’s physiological responses to sedation during procedure• Physician directed, may be registered nurse performed• Physician and registered nurse must have demonstrated competency• Proctored for assurance of competency on new procedures & techniques


PERFORMANCE IMPROVEMENT

Performance Improvement


Expectations:

• Interdepartmental performance improvement activity (CQI teams, etc.)• Intradepartmental performance improvement activity• Quality control activity• Peer review and competency (quality assessment and improvement)



DEMONSTRATED PERFORMANCEIMPROVEMENT SUCCESS



QUALITY CONTROL ACTIVITY

Nuclear Medicine Department Survey Workbook

Technology

nuclear medicine post

jcaho survey process

days of survey

survey dates

actual survey process

correct answer

surveyors question

staff members